LASIK following previous eye Surgery

Transcription

1 AAO Anaheim 2003 Course 584 Nov18th, 2-415PM LASIK following previous eye Surgery A. John Kanellopoulos, MD Associate Clinical Professor, NYU Medical School Director: Laservision.gr Eye Institute, Athens, Greece

2 Review of the scientific literature Published reports on lasik after other surgical procedures are limited Lasik is still in its infancy and large series of patients who have undergone other surgical procedures are lacking As more surgeons perform lasik, more data will be reported on eyes that have had other surgical procedures prior to lasik

3 Lasik after Penetrating Keratoplasty Eventhough the success rates of PKP are high certain conditions still limit quality of vision. These include: High ammetropia High astigmatism/irregular astigmatism Anisometropia Spectacle intolerance CL intolerance

4 Lasik after PKP Review of the Literature 10 published reports Number of eyes reported ranged from 4 to 26 Mean time interval between PKP and Lasik ranged from 12 mos to 23 years 90/119 eyes reported had keratoconus as the diagnosis prior to PKP Mean age 38.6 years (19-80 years)

5 Lasik after PKP Review of the Literature Mean time interval between final suture removal and Lasik only one published study reports this information: Donnenfeld et al: 35.3 months Minimum time interval between final suture removal and Lasik ranged from 3-10 months

6 Lasik after PKP Microkeratomes used: 5 studies report using the ACS; 1 study Moria LSK and 1 study did not state which keratome was used. Spacer plates used: both 160 micron and 180 micron plates were used

7 Lasik after PKP Review of the Literature Lasers used: Nidek: 1 VISX 20/20: 2 Summit Apex Plus: 1 Meditec: 1 Technolas 116: 1 One study did not state model excimer used

8 Lasik After PKP Published Results 110 eyes reported in 8 publications Range of Follow Up Periods: 6-12 months Mean Myopic Preop. Sph. Eq.: -8.47D Range of myopia treated was 2.25D to D Mean Preop Cyl. in Myopic eyes: D Range of Preop Cyl.treated : -2D to 15D

9 Lasik After PKP Published Results Mean Post Op Sph. Eq.: est 0.67D Range of Post op Sph. Eq.: D Mean Post op Cyl.: -2.08D Range of Post op Cyl.: to 7D

10 Lasik After PKP Reduction in Myopia Lima (Can J. Ophth 2001) 91% reduction (23) Donnenfeld (Ophth 1999) 85.6% (23) Forseto (JCRS 1999) 85.3% (22) Webber (BJO 1999) 74.8% (18) Kwitko (JCRS 2001) 90% (9) Arenas (JRS 1997) 78% (4) Lam (JCRS 1998) 64.8% (2) Parisi (JCRS 1997) 100% (1)

11 Lasik After PKP Reduction in Astigmatism Lima (Can J. Ophth 2001) 60% reduction (23) Donnenfeld (Ophth 1999) 45.6% (23) Forseto (JCRS 1999) 58.3% (22) Webber (BJO 1999) 65.8% (18) Kwitko (JCRS 2001) 47.4% (9) Lam (JCRS 1998) 66.3% (2) Parisi (JCRS 1997) 40% (1) Reduction was in absolute # as vector analysis was not performed in all studies

12 Gain of >/=1 lines BCVA following Lasik After PKP Lima (Can J. Ophth 2001) 8 eyes (35%) Donnenfeld (Ophth 1999) 12 eyes (52%) Forseto (JCRS 1999) 9 eyes (41%) Webber (BJO 1999) 15 eyes (58%) Kwitko (JCRS 2001) 4 (44%) Lam (JCRS 1998) Not reported Parisi (JCRS 1997) 0 (0%)

13 Loss of >/=1 lines BCVA following Lasik After PKP Lima (Can J. Ophth 2001) 2 eyes (9%) Donnenfeld (Ophth 1999) 2 eyes (9%) Forseto (JCRS 1999) 2 eyes (9%) Webber (BJO 1999) 3 eyes (12%) Kwitko (JCRS 2001) 5 (36%) Lam (JCRS 1998) Not reported Parisi (JCRS 1997) 0 (0%)

14 Post op UCVA >/= 20/40 Lima (Can J. Ophth 2001) 78% Donnenfeld (Ophth 1999) 36%* Forseto (JCRS 1999) 54.5% Webber (BJO 1999) 28% Kwitko (JCRS 2001) 33% Lam (JCRS 1998) 50% Parisi (JCRS 1997) Not reported

15 PKP Lasik After Hyperopia Range of Follow Up Periods: 6-12 months Mean Hyperopic Preop. Sph. Eq.: +4.74D Range of Hyperopia treated was +1.50D to D Mean Preop Cyl. in Hyperopic eyes: D Range of Preop Cyl.treated : -1.5D to 6D

16 Lasik After PKP --Hyperopia Mean Post Op Sph. Eq.: Range of Post op Sph. Eq.: to Mean Post op Cyl.: -1.81D Range of Post op Cyl.: -0.5 to 5.50D

17 Lasik After PKP Reduction in Hyperopia Lima (Can J. Ophth 2001) 77% (4) Kwitko (JCRS 2001) 79% (5)

18 Lasik After PKP Reduction in Astigmatism Lima (Can J. Ophth 2001) 88% (4) Kwitko (JCRS 2001) 79% (5)

19 Regression and Retreatments Not reported in all studies: Kwitko reported retreatment rate of 42.9% because of cyl undercorrection Stabilization of the postop refraction appears to occur at one month (Lima, Forseto, Donnenfeld) with no significant change at 6 months Tendency for eyes to remain undercorrected

20 Lasik After PKP Complications Increased astigmatism postop: 5 cases Epithelial Ingrowth1,2 Hemorrhage into the flap: 1 case Microkeratome Jam on suture: 1 case Buttonhole: 1 case Flap dislocation day: 1 case 1 day postop Decentered ablation:1 case RD: 1 case pseudophakic 2 years post lasik

21 Complications that were not seen Wound dehiscence at the graft host junction 0% incidence Striae Unstable refractions postoperatively Graft rejections Significant endothelial cell loss Overcorrection

22 Recommendations For Performing Lasik After PKP Perform in those pts who have significant anisometropia and/or astigmatism who are spectacle and/or CL intolerant Present realistic expectations to pts-you are attempting to reduce their ametropia to get them into spectacles Perform no sooner than 6 months after all sutures have been removed but the longer you wait the better Wait for refractive and topographic stability

23 Recommendations For Performing Lasik After PKP Center flap over the pupil Avoid the microkeratome incision at the graft-host junction-begin 1mm outside or inside the graft host junction Experience counts the longer you keep suction on the eye the greater the chance of wound dehiscence Use steroids for a longer period of time (Sen JCRS 2002) at least two weeks

24 Further Data Required Position of Hinge and its effect on outcome Effect of creating the flap on refractive change Flap thickness Effect of newer generation lasers with smaller spot sizes and tracking capabilities Wavefront technology and topographically linked lasik should improve results

25 LASIK After Cataract Surgery Author Laser Used Microkeratome Used Mean Interval between Procedures Ayala et. al. JRS 2001 NIDEK EC ACS 10 mos. (3 72 mos)

26 LASIK After Cataract Surgery Author Num. of Eyes Mean Pre-Op Sph. Eq. Mean Post-Op Sph. Eq. Mean Pre-Op Astigmatism Mean Post- Op Astigmatism Ayala et. al D D * JRS 2001 (-0.80 to -8.50D) (-0.6 to +1.50D) (-0.25 to -6.50D) * Not significant

27 LASIK After Cataract Surgery Author > 20/40 > 20/20 Ayala et. al. JRS % 0% BSCVA after LASIK was significantly better before LASIK at 3, 6 and 12 month periods.

28 LASIK After Cataract Surgery Author + 0.5D Emmetropia + 1.0D Emmetropia Ayala et. al. JRS % (11) 81.8% (18)

29 LASIK After Thermal Keratoplasty Author Laser Used Microkeratome Used LTK Unit Interval between Procedures Portellinha et. al. JRS 1999 NIDEK ACS 160/8.5 Fyodorov >2 yrs. Attia et. al. JRS 2000 B&L Tech 217 ACS 160/8.5 Sunrise 18 mos.

30 LASIK After Thermal Keratoplasty Author Num of Eyes Mean Pre-Op Sph. Eq. Mean Post-Op Sph. Eq. Pre-Op Astigmatis m Post-Op Astigmatis m F/U Portellinh a et. al. JRS (+1 to +6.50) +0.88D (0 to +1.50D) -0.48D (0 to 2.0D) -0.38D (0 to 1.5D) 1 yr. Attia et. al. JRS (+0.50 to +6.50) (-2.75 to +3.75) 6 mos.

31 LASIK After Thermal Keratoplasty Author > 20/40 > 20/25 Loss of BCVA Gain of BCVA Portellinha et. al. JRS % 66% 25% lost 1 line 8% gained 1 line Attia et. al. JRS % 46% 14% lost 1 line 16% 34% gained 1 line lost 2 lines

32 LASIK After Thermal Keratoplasty Author + 0.5D + 1.0D Portellinha et.al. JRS % 67% Attia et. al. JRS % 60% No complications including no morphological changes on radial thermal scars. At 24 months, undercorrection 33% (+1.25 to +1.50D). At 6 months, 26% had regression.

33 Indications Penetrating keratoplasy Pseudophakia Glaucoma Sx Radial / Astigmatic keratotomy Retinal Surgery PRK/ Lasik Bioptics

34 LASIK Following Radial Keratotomy Special Concerns Treat epithelial inclusions and wound gapes prior to LASIK (re-suture if ness.) Careful surface marking Carefully handle flap to avoid tearing RK along incisions Thicker flaps Enhancements difficult Higher incidence of DLK?

35 LASIK following Radial Keratotomy PERK Study: 43% of eyes had a 1D hyperopic shift at 10 years Following LASIK 91% improvement or no change in BCVA 1 Following LASIK no loss of 2 lines in BCVA 2 1 Attia. Journal of Cataract and Refractive Surgery, Lindstrom. Ophthalmology, 2000

36 LASIK following Radial Keratotomy Hyperopic shift/ Visual fluctuation may continue Ineffective for irregular astigmatism (except with wavefront-guided and/or topo-guided)

37 50 y/o male, s/p RK for about 8 in USSR 1990 UCVA 20/40-, 20/ /25 (8/10) /25- (7/10) Significant night glare (dec)

38 Pre-op

39 Post-op

40 46 y/o male 10 years s/p RK for x? and subsequent hyperopic shift

41 46 y/o male 10 years s/p RK for x? and subsequent hyperopic shift sc: 20/80 diplopia Rx x 17 gives 20/25 LASIK with the Moria M2 and the Allegretto-wave Post-op 3 months: Sc 20/30! x 40 20/25

42 LASIK Following Penetrating Keratoplasty 39-70% of PK s are within 3D of emmetropia Mean cylinder following PK is 4-5 D Following LASIK 100% are within 3 D emmetropia 1 91% of eyes BCVA remained the same or improved 1 Contact lens remains standard of care 1 Donnenfeld. Ophthalmology, 1999

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44 LASIK Following Penetrating Keratoplasty Special Concerns Avoid graft-host interface Flap adherence 5 minutes Increased postoperative corticosteriods Endothelial dysfunction and flap slippage 1 Keratoconus and progressive ectasia 1 Donnenfeld. ASCRS, 2001

45 34 y/o male 2 years s/p Therapeutic PK for a CL-related ulcer Good cell counts: top= OD unaffected eye Bottom= OS eye with PK Rx x 56 with the Allegretto-wave Post-op 3 months: Sc 20/30! x 50 20/25

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47 Wavefront Regular pattern Refraction differs with larger apeture

48 LASIK Following Cataract Surgery No significant concerns with PC/IOL Careful with endothelial dysfunction around phaco wound site (flap slippage, poor adhesion)? PRK with AC/IOL Future of cataract surgery

49 LASIK and the Glaucoma Patient Absolute Contraindications Filtering/Valve Surgery -End stage disease Significant ON damage and/or Visual Field Loss Uncontrolled Glaucoma More than 2 Medications

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51 LASIK and the Glaucoma Patient Special Concerns Epithelial Sloughing: Discontinue topical meds pre-op Oral CAIs Nerve Fiber Layer Analysis(HRT, GDx) Post-operative IOP Measurement Mean Decrease in IOP is 4.3 mm Hg 1 Beware of low IOP and progressive ON damage (interface fluid-maloney Ophathalmology2002) 1 Danasoury. Journal ofrefractive Surgery, 2001

52 LASIK Following Retinal Detachment Pre-LASIK vitreoretinal consultation Avoid LASIK in high buckles-risk of poor suction/ irregular flap Treatment of asymptomatic holes controversial Avoid silicone oil eyes

53 LASIK after Previous PRK Central keratometry/ Orbscan Consider Epithelial hyperplasia (If suspected plan for thicker flap) Increased postoperative steroids

54 LASIK after Previous LASIK Relift flap if possible (unless limited by thin cornea) Undercorrect consecutive ametropia 1 1 Jacobs. Journal of cataract and refractive surgery, 2001

55 LASIK after Previous LASIK New flap should be larger and deeper than the original flap or narrower and thinner (the same MK will cut a thinner consecutive flap on a thinner cornea) Posterior flap ablation when residual stromal bed not adequate (not possible with flying-spot excimers) Personal preference: minimum cornea thickness> 400nm 35<K s<49

56 BIOPTICS: Artisan phakic IOL and staged LASIK A. John Kanellopoulos, MD Manhattan Eye, Ear and Throat Hospital ASCRS 1999

57 Background Unable to correct high myopes > 12-14D with LASIK Growing interest in phakic IOL s Anterior chamber (haptics, iris fixated) Posterior chamber

58 Methods Evaluated 12 patients with myopia > 10 D Initial flap formation 2-5 days later Artisan implantation 6 weeks later LASIK enhancement for RE > 0.50 D Follow-up 1D, 1Week, 1 month, 3Months, 6 Months

59 Results 12 eyes mean RE: D At 6 weeks mean RE: -2.50D 10 eyes received enhancement Postoperative RE: -0.45

60 Results Va BCVA UCVA Preop 20/45 CF Postop 20/27 20/42

61 Complications IOP spike s ECC loss Under Crctn > 0.50 Epi ingrowth Glare Halos Artisa n 0 +2 %! Enhan cement %! 0 1(Ns) 2

62 Artisan

63 Endothelial cell counts

64 Case report 1 patient randomized for one IOL each eye Artisan OD: X 90 UCVA 20/25 ICL OS: UCVA 20/25+ Outflow facility: unchanged OD (0.285 to microl/min/mmhg), reduced from to 0.185) 35.5% OS

65 27y/o F 14.00, -9.00

66 OD Bioptics 6 months postop 20/20

67 OS Lasik 8 months postop 20/25

68 Conlcusions Good predictable approxim of emmetropia Artisan require more surgical skill and elaborative technique Away from K, angle, crystalline lens Minimal if any ECC loss

69 My technique 1 Drop of Alcaine Betadine scrub and drape eyelids Aspirating speculum Lubricate blade and rotating parts with Alcaine!!!

70 Placement of the M2 Push down untill good suction, then lift

71 Microkeratome pass Observe patient anxiety and squeeze

72 My technique Fold flap onto itself to minimize Dehydration and exposure (minimal manipulation) Even bed hydration very dry technique (hinge ½ most moist)

73 ABLATION: Check parameters! (last chance to avoid error) Intraoperative moistute eq if needed

74 Irrigation of flap and careful wipe (remove fluid from interface)

75 My technique Irrigation very important Squeeze out excees fluid and Striae with moist Weck-cell Suspension-opaque drop (predforte 1%) to delineate gutter width, centration and possible striae

76 Attempt to compensate for irregular hydration state of the flap during the procedure (excimer, procedure speed)

77 Is the flap back in place?

78 1 observation interval Flap is evaluated with build-in slit-lamp

79 Video

80 Conclusion With intelligent pre-operative selection and surgical planning, LASIK can be invaluable in the visual rehabilitation of patients following previous ocular surgery.

81 Thank You